Preoperative Assessment in PrivatePractical Pointers for Private Practitioners

Dr Adam Molnar

MBBS FANZCA

Victorian Anaesthetic Group

Victorian Anaesthetic

Group

Conflict of Interest

Family member owns MediTrust

I have no financial interest in the product

I act as a medical consultant to MediTrust

I have never received a payment in the past from MediTrust

I will not receive a payment in the future from MediTrust

I pay a commercial rate to use the product

My Practice

Full time private practice

Victorian Anaesthetic Group

Inner Melbourne

Major orthopaedic, colorectal, reconstructive plastic, gynaecology and endoscopy.

IT interest

Private Practice in Australia

Around 2 million anaesthetics are given privately in Australia per year

4% increase in procedures per year

Increasing complexity of cases

Increasing age of patients

Little or no current research on preoperative assessment in private

Preoperative Evaluation

Cardiac –Fleischer LA et al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2007

Respiratory-Bapoje SR et al. Preoperative evaluation of the patient with pulmonary disease. Chest 2007

Diabetes

OSA

Airway

The Problem

Approaching 100% same day admission

Staggered admission

Increasing pressure to provide more information

Compared to public there is a decrease waiting period

Surgeons notify anaesthetists late regarding particular cases

Patient information is on multiple systems which do not interface

Preoperative Assessment

Establish Rapport ✔

History ✔

Examination ✔

Investigations ✔

Anaesthetic Plan ✔

Informed Consent ✔

Anaesthetic

Australian Incident Monitoring Study

Kluger MT et al Inadequate preoperative evaluation and preparation: A review of 197 reports from AIMS. Anaesthesia 2000

3.1% of adverse events

Preventable in 57% of cases

23 major cases of morbidity. 7 deaths

10% of patients had not been seen

29% poor airway assessment

Victorian Consultative Council on Anaesthetic Mortality and Morbidity

Continually emphasis the contribution of poor preoperative assessment to morbidity and mortality

“These included failure to identify patient information details, poor medical status evaluation, inadequate airway assessment, and failure to adequately assess the cardiovascular system.”

15%anaesthetic related mortality

12%anaesthetic related morbidity

Preoperative Assessment in Private

Anaesthetic Consults

Total Services Distribution

17610 < 15 minutes 1935086 92.6 %

17615 15 to 30 minutes

102746 4.9%

17620 30 to 45 minutes

13418 0.6%

17625 >45 minutes 2617 0.1%

17690 In Rooms 36437 1.8%

Preoperative AssessmentTechniques

Rely on surgeon assessment and investigation

In room consultations

Perioperative physicians

Phone consultations

Hospital Pre-anaesthetic Clinics

Online solutions

Preoperative Assessment in Rooms

State % Total Anaesthetic Consultations

Tasmania 4.5%

Western Australia 3.1%

New South Wales 2.9%

South Australia 2.2%

ACT 1.5%

Queensland 0.5%

Victoria 0.4%

Northern Territory 0.3%

Preoperative Assessment in Rooms

2008 2009 20100

0.51

1.52

2.53

3.54

4.55

TasWANSWSAACTQLDVICNT

In Rooms Consultation

Probably the gold standard

Costly

Difficult to see all patients – need to screen

May see patients too late

In Rooms Consultation

In Room Consultation

Perioperative Physician

Renal or general physician

Patient referred by the surgeon

Complete 24/7 cover

Advantages- organise appropriate investigations, optimise medical conditions, send summary to anaesthetist prior to surgery, provide cover.

Disadvantages-lack understanding of the operative process, no anaesthetic discussion, inadequate pain control.

Phone consultations

Patients like them

Advantages- History, anaesthetic discussion, screen patients prior to seeing in rooms

Disadvantage – Inefficient, examination and investigation problems, late referrals

Hospital Pre-anaesthetic Clinic

Set up by hospitals

Run by nursing staff

Advantages- History, screen patients prior to seeing in rooms

Disadvantages- Late referrals, no examination or investigations, no anaesthetic discussion

On-line assessment

Increase use of internet, smart phones and tablets

Capture patient at time of surgical booking

Anaesthetist introduced

Specific anaesthetic information

Provides specific informed financial consent

Health survey

Screen for in room consultation

Day of Surgery Admission

Appropriate facilities

Access to rapid investigations

Access to ICU/HDU beds

Willingness to cancel

Preoperative Assessment

Challenging

Anaesthetists need to be prepared to adapt

Anaesthetists must maintain their high professional standards

Anaesthetists must be involved in the process of change